Table 3

Context–mechanism–outcome configurations and supporting evidence

Brief titleFull context–mechanism–outcome configurationReferences
Understanding behaviour as communication to improve staff’s ability to respondWhere behaviours that challenge are understood as communication of an unmet need (context), through training, resources and support from experts in dementia care (mechanism resource), staff will feel they have improved capacity and capability to influence the situation (mechanism reasoning), making it more likely they will identify and address the need (outcome).
However
Conflicting work demands, patient characteristics (context) and staffing resources (mechanism resource) may lead staff to feel they are unable to make a difference (mechanism reasoning), meaning patient need might not be recognised, investigated or addressed (outcome).
10 15 39–57 59 60
The role of experiential learning and creating empathy to encourage reflection for responsibilities of careAccess to training (context) that promotes experiential learning and empathy towards people living with dementia (mechanism resource) can encourage reflection that identifies deficiencies in current working practices, helping staff to understand their responsibilities for care (mechanism reasoning) and leading them to take more time with people living with dementia (outcome).
However
Where good dementia care practices (mechanism resource) are not considered legitimate working practices (context), staff may consider these practices as additional to their workload (mechanism reasoning), leading to inconsistent provision of care (outcome).
10 39 46–49 51 53
Clinical experts who legitimise priorities for careClinical experts who have the authority to legitimise priorities and standards for dementia care endorsed by the organisation (context) provide support for staff to develop skills in dementia care (mechanism resource) and can help staff feel confident of the expectations for their role (mechanism reasoning) to adapt working practices (outcome).
However
By focusing the responsibility for dementia care in select staff (context/mechanism resource), there may be a reduced sense of responsibility for dementia care in the wider workforce (mechanism reasoning), reducing the ability of experts to embed good dementia care practices across the organisation (outcome).
39–41 44–49 52–54 59 60 62 63
Staff with confidence to adapt working practices and routines to individualise careStaff supported to be flexible in their role and working environment (context), where their responsibilities for patient care have been clarified (mechanism resource), may be responsive or adaptive in their decision-making (mechanism reasoning) to provide care and treatment to a person in a timely, individualised manner (outcome).
However
Changes to staff capacity or environmental adaptations (context/mechanism resource) may need to be recognised and addressed by management (mechanism reasoning) to support staff to provide responsive care (outcome).
45 46 48 54 60
Staff with responsibility to focus on psychosocial needsWhere there is provision of activities and therapies for people living with dementia that support their interests and abilities (context) by staff with a role to address psychological, emotional and social issues (mechanism resource) and responsibility (mechanism reasoning) for maintaining functional and cognitive abilities (outcome), this can provide other healthcare staff with time to prioritise physical and medical needs (outcome).
However
Where staffing resources are limited (context), staffing for activity and therapy can be reallocated to maintaining patient safety (mechanism resource), which may require staff to prioritise safety concerns (mechanism reasoning), limiting their ability to meet psychosocial needs (outcome).
10 44–46 48 50 52 53 56 58 61
Building staff confidence to provide person-centred risk managementWhere procedures and expectations for care are set out to address risk in a person-centred way (context), and are encouraged and reinforced through ward leadership (mechanism resource), staff may feel confident to address risk proportionately (mechanism reasoning) and may support patients with dementia to maintain function and abilities in a less restrictive way (outcome).
However
Resources will need to be compatible with environmental features and staff capacity (context/mechanism resource) or staff may not feel there is a value to their work or for the patient (mechanism reasoning), making it unlikely they will adapt care practices (outcome).
10 15 41 43–45 51–53 56–58 63